COVID-19 Acknowledgement Form

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Please complete this form prior to each clinic session. Thank you

Email *

Player Last Name *

Player First Name *

Date of Session *

YYYY

Within the last 14 days has your child been diagnosed with COVID-19 or had a test confirming they had the virus? *

Yes

Does your child live in the same household, or have they had close contact (been within 6 feet for over 10 minutes) with someone who has been in isolation for COVID-19 or has had a test confirming they have the virus, in the past 14 days? *

Yes

Has your child had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by another reason? (Fever of at least 100.4 or chills, Cough, Shortness of breath or difficulty breathing, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) *

Yes

By submitting this form you are acknowledging that all of the information is true and correct. Please add the name of the person filling out this form. *

A copy of your responses will be emailed to the address you provided.

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